US in non-traumatic acute abdomen. Lalita, M.D. Radiologist Department of radiology Faculty of Medicine ChiangMai university
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1 US in non-traumatic acute abdomen Lalita, M.D. Radiologist Department of radiology Faculty of Medicine ChiangMai university
2
3 Sagittal Orientation
4 Transverse (Axial) Orientation
5 Coronal Orientation
6 Intercostal Imaging plane
7 : Hyperechoic 2: Hypoechoic 3: Anechoic 4: Posterior acoustic enhancement 5: Posterior acoustic shadow
8 Specific terms for US Hyperechoic : White Fat, air, calcification Posterior acoustic shadow Hypoechoic : Grey Soft tissue, turbid fluid Anechoic : Black Clear fluid cyst, gallbladder, bile duct, vessels Posterior acoustic enhancement
9 Liver abscess
10 Liver abscess Early suppuration: solid with altered echogenicity, usually hypoechoic
11 Liver abscess Frankly purulent: cystic, with the fluid ranging from echo free to highly echogenic Posterior enhancement
12 Liver abscess Gas-producing: echogenic foci with a posterior reverberation artifact Fluid-fluid interfaces, internal septations, debris Wall: well defined, irregular, thick
13 Specific terms for US Reverberation artifact Gas Additional echo from repeat reflection (two strong parallel reflectors) Series of bright bands (step ladder) Cannot see image beneath the gas
14 Liver abscess HCC
15 1 2
16 Gallstones 15-20% GS: detect on plain film. US: most sensitive in detection of GS Mobile Echogenic structure Acoustic shadowing in the lumen of the gallbladder
17
18
19 Impacted gallstone A gallbladder completely filled with stones Wall-echo-shadow (WES) complex 1 st line: GB wall 2 nd line: bright echo of the stone 3 rd line: acoustic shadowing
20 Acute cholecystitis Gallstones Gallbladder wall thickening > 3 mm Gallbladder enlargement > 4x10 cm Positive sonographic Murphy s sign Pericholycystic fluid
21
22
23 1 Gallstone with acute cholecystitis 2 Symptomatic gallstone
24 Renal stone
25 Calculi Common finding, in collecting system Multiple predisposing conditions: No cause is identified in most patients Most are hyperechoic with posterior acoustic shadowing Non-obstructing caliceal calculi: usually asymptomatic*
26 Calculi US: Sensitivities in detection of calculi is 12% to 96% Depend on location (renal or ureteral), composition, and sizes of calculi Stones greater than 5 mm were detected with 100% sensitivity by ultrasound Operator technique clearly impacts the ability of ultrasound to depict renal calculi
27
28 2
29
30 Calculi Color Doppler may also improve the detection of small, minimally shadowing 83% urinary tract stones show color and power Doppler sonographic twinkling artifacts
31 2
32
33
34 4
35 A B
36 Anatomy Normal kidney. A, Sagittal, and B, transverse, sonograms of normal anatomy with corticomedullary differentiation show relatively hypoechoic medullary pyramids, with cortex slightly less echogenic than the liver and spleen.
37 A B
38 Nephrocalcinosis Renal parenchymal calcification The calcification may be dystrophic or metastatic Dystrophic: deposition of calcium in devitalized (ischemic or necrotic) tissue : tumors, abscesses, hematoma Metastatic: most often with hypercalcemic states caused by hyperparathyroidism, RTA, and renal failure : cortical or medullary
39
40
41 Renal stone 1 renal stone 2 small renal stones 3 renal stone 4 medullary nephrocalcinosis
42 Stone? 1. Yes 2. No
43 2
44 Renal artery calcification
45 ENTITIES THAT MIMIC RENAL CALCULI Intrarenal gas Renal artery calcification Calcified sloughed papilla Calcified transitional cell tumor Alkaline-encrusted pyelitis Encrusted calcification of ureteric stent
46 Calculi If a stone passes into the ureter: three areas of ureteric narrowing: uteropelvic junction (UPJ) ureter crosses the iliac vessels ureterovesical junction (UVJ).
47 Ureteral calculi Difficult at sonography because of overlying bowel gas and the deep retroperitoneal location of the ureter Identified as hyperechoic focus with sharp, distal acoustic shadowing within the ureteric lumen
48
49 Left RC with mild hydronephrosis
50 Moderate hydronephrosis
51 Severe hydronephrosis
52 Low level echoes within the dilated PCS may represent pus. Sometimes, the urine may appear anechoic, despite being infected. The clinical history should help differentiate pyo- from simple hydronephrosis. Pyonephrosis
53 Appendix
54 Acute appendicitis A positive sonographic McBurney sign Blind-ending tubular structure Greater than 6 mm in outer diameter Non-compressible The increased flow in the appendiceal wall or periappendiceal space using color Doppler sonography
55 An additional positive finding An appendicolith Peritoneal fluid Hyperechoic periappendiceal fat Cecal wall thickening A RLQ fluid collection without visualization of the inflamed appendix raised suspicion for perforated appendicitis and periappendicular abscess.
56 Appendicitis
57 Appendicitis with appendicolith
58 Thank you
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